The 5-Factor Modified Frailty Index is a Concise and Effective Predictor of 30-Day Adverse Outcomes in Carotid Endarterectomy.

INTRODUCTION: Frailty is a clinically identifiable condition characterized by heightened vulnerability. The 5-item Modified Frailty Index provides a concise calculation of frailty that has proven effective in predicting adverse perioperative outcomes across a variety of surgical disciplines. However, there is a paucity of research examining the validity of 11-item Modified Frailty Index (mFI-5) in carotid endarterectomy (CEA). This study aimed to investigate the association between mFI-5 and 30-day outcomes of CEA. METHODS: Patients underwent CEA were identified from American College of Surgeons National Surgical Quality Improvement Program targeted database from 2012 to 2021. Patients with age<18 were excluded. Patients were stratified into four cohorts based on their mFI-5 scores: 0, 1, 2, or 3+. Multivariable logistic regression was used to compare 30-day perioperative outcomes adjusting for preoperative variables with P value<0.1. RESULTS: Compared to controls (mFI-5 = 0), patients mFI-5 = 1 had higher risk of stroke (adjusted odds ratio [aOR] = 1.333, P = 0.02), unplanned operation (aOR = 1.38, P < 0.01), and length of stay (LOS) > 7 days (aOR = 0.814, P < 0.01). Patients with mFI-5 = 2 had higher stroke (aOR = 1.719, P < 0.01), major adverse cardiovascular events (MACE) (aOR = 1.315, P = 0.01), sepsis (aOR = 2.243, P = 0.01), discharge not to home (aOR = 1.200, P < 0.01), 30-day readmission (aOR = 1.405, P < 0.01). Compared with controls, patients with mFI-5≥3 had higher mortality (aOR = 1.997 P = 0.02), MACE (aOR = 1.445, P = 0.03), cardiac complications (aOR = 1.901, P < 0.01), pulmonary events (aOR = 2.196, P < 0.01), sepsis (aOR = 3.65, P < 0.01), restenosis (aOR = 2.606, P = 0.02), unplanned operation (aOR = 1.69, P < 0.01), LOS>7 days (aOR = 1.425, P < 0.01), discharge not to home (aOR = 2.127, P < 0.01), and 30-day readmission (aOR = 2.427, P < 0.01). CONCLUSIONS: The mFI-5 is associated with 30-day mortality and complications including stroke, MACE, cardiac complications, pulmonary complications, sepsis, and restenosis. Additionally, elevated mFI-5 scores correlate with an increased likelihood of unplanned operations, extended LOS, discharge to facilities other than home, and 30-day readmissions, all of which could negatively impact long-term prognosis. Therefore, mFI-5 can serve as a concise yet effective metric of frailty in patients undergoing CEA.

The deimplementation of laboratory testing in low-risk patients as recommended by the American society of anesthesiologists: An ACS-NSQIP longitudinal analysis.

BACKGROUND: In 2012, the American Society of Anesthesiologists (ASA) published guidelines recommending against routine preoperative laboratory testing for low-risk patients to reduce unnecessary medical expenditures. The aim of this study was to assess the change in routine preoperative laboratory testing in low-risk versus higher-risk patients before and after release of these guidelines. METHODS: The ACS-NSQIP database, 2005-2018, was separated into low-risk versus higher-risk patients based upon a previously published stratification. The guideline implementation date was defined as January 2013. Changes in preoperative laboratory testing over time were compared between low- and higher-risk patients. A difference-in-differences model was applied. The primary outcome included any laboratory test obtained ≤90 days prior to surgery. RESULTS: Of 7,507,991 patients, 972,431 (13.0%) were defined as low-risk and 6,535,560 (87.0%) higher-risk. Use of any preoperative laboratory test declined in low-risk patients from 66.5% before to 59.6% after guidelines, a 6.9 percentage point reduction, versus 93.0%-91.9% in higher-risk patients, a 1.1 percentage point reduction (p < 0.0001, comparing percentage point reductions). After risk-adjustment, the adjusted odds ratio for having any preoperative laboratory test after versus before the guidelines was 0.77 (95% CI 0.76-0.78) in low-risk versus 0.93 (0.92-0.94) in higher-risk patients. In low-risk patients, lack of any preoperative testing was not associated with worse outcomes. CONCLUSIONS: While a majority of low-risk patients continue to receive preoperative laboratory testing not recommended by the ASA, there has been a decline after implementation of guidelines. Continued effort should be directed at the deimplementation of routine preoperative laboratory testing for low-risk patients.

Mortality and failure-to-rescue after esophagectomy in the procedure-targeted National Surgical Quality Improvement Program registry.

BACKGROUND: The association between procedural volume and esophagectomy outcomes has been established, but the relationship between higher levels of care and esophagectomy outcomes has not been explored. This study aims to investigate whether hospital participation in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) esophagectomy-targeted registry is associated with superior outcomes. METHODS: The 2016-2020 ACS NSQIP standard and esophagectomy-targeted registries were queried. Esophagectomy outcomes were analyzed overall and stratified by esophagectomy type (Ivor Lewis vs. transhiatal vs. 3-field McKeown). RESULTS: A total of 2181 and 5449 esophagectomy cases were identified in the standard and targeted databases (68% Ivor Lewis esophagectomy). The median age was 65 years and 80% were male. Preoperative characteristics were largely comparable. On univariate analysis, targeted hospitals were associated with lower mortality (2% vs. 4%, p < 0.01) and failure-to-rescue rates (11% vs. 17%, p < 0.01), higher likelihood of an optimal outcome (62% vs. 58%, p = 0.01), and shorter hospital stay (median 9 vs. 10 days, p < 0.01). On multivariable analysis, Ivor Lewis esophagectomy at targeted centers was associated with reduced odds of mortality [odds ratio (OR) 0.57 and 95% confidence intervals 0.35-0.90] and failure-to-rescue [OR 0.54 (0.33-0.90)] with no difference in serious morbidity or optimal outcome. There was no statistically significant difference in odds of mortality or failure to rescue in targeted versus standard centers when performing transhiatal or McKeown esophagectomy. CONCLUSIONS: Esophagectomy performed at hospitals participating in the targeted ACS NSQIP is associated with roughly half the risk of mortality compared to the standard registry. The factors underlying this relationship may be valuable in quality improvement.

Evaluation of the American College of Surgeons risk calculator in hepatectomy for metastatic colorectal cancer in a Southeast Asian population.

PURPOSE: This study evaluated the accuracy of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) calculator in predicting outcomes after hepatectomy for colorectal cancer (CRC) liver metastasis in a Southeast Asian population. METHODS: Predicted and actual outcomes were compared for 166 patients undergoing hepatectomy for CRC liver metastasis identified between 2017 and 2022, using receiver operating characteristic curves with area under the curve (AUC) and Brier score. RESULTS: The ACS-NSQIP calculator accurately predicted most postoperative complications (AUC > 0.70), except for surgical site infection (AUC = 0.678, Brier score = 0.045). It also exhibited satisfactory performance for readmission (AUC = 0.818, Brier score = 0.011), reoperation (AUC = 0.945, Brier score = 0.002), and length of stay (LOS, AUC = 0.909). The predicted LOS was close to the actual LOS (5.9 vs. 5.0 days, P = 0.985). CONCLUSION: The ACS-NSQIP calculator demonstrated generally accurate predictions for 30-day postoperative outcomes after hepatectomy for CRC liver metastasis in our patient population.

Surgical Management of Breast Capsular Contracture-A Multi-institutional Data Analysis of Risk Factors for Early Complications.

BACKGROUND: Capsular contracture (CC) is a common complication following implant-based breast surgery, often requiring surgical intervention. Yet, little is known about risk factors and outcomes following CC surgery. METHODS: We reviewed the American College of Surgeons National Surgical Quality Improvement Program database (2008-2021) to identify female patients diagnosed with CC and treated surgically. Outcomes of interest included the incidence of surgical and medical complications at 30-days, reoperations, and readmissions. Confounder-adjusted multivariable analyses were performed to establish risk factors. RESULTS: 5,057 patients with CC were identified (mean age: 55 ± 12 years and mean body mass index [BMI]: 26 ± 6 kg/m2). While 2,841 (65%) women underwent capsulectomy, capsulotomy was performed in 742 patients (15%). Implant removal and replacement were recorded in 1,160 (23%) and 315 (6.2%) cases, respectively. 319 (6.3%) patients experienced postoperative complications, with 155 (3.1%) reoperations and 99 (2.0%) readmissions. While surgical adverse events were recorded in 139 (2.7%) cases, 86 (1.7%) medical complications occurred during the 30 day follow-up. In multivariate analyses, increased BMI (OR: 1.04; p = 0.009), preoperative diagnosis of hypertension (OR: 1.48; p = 0.004), and inpatient setting (OR: 4.15; p < 0.001) were identified as risk factors of complication occurrence. CONCLUSION: Based on 14 years of multi-institutional data, we calculated a net 30 day complication rate of 6.3% after the surgical treatment of CC. We identified higher BMI, hypertension, and inpatient setting as independent risk factors of postoperative complications. Plastic surgeons may wish to integrate these findings into their perioperative workflows, thus optimizing patient counseling and determining candidates' eligibility for CC surgery. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Gynecomastia Surgery in 4996 Male Patients Over 14 Years: A Retrospective Analysis of Surgical Trends, Predictive Risk Factors, and Short-Term Outcomes.

BACKGROUND: The high prevalence of benign male breast tissue enlargement (gynecomastia) has resulted in a marked increase of gynecomastia cases. While about one third of male adults experience some form of gynecomastia, gynecomastia surgery (GS) outcome research is limited to small study populations and single-center/-surgeon databases. In this study, we aimed to access the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify preoperative risk factors for complications and investigate postoperative outcomes of GS. METHODS: In this retrospective study, we queried the ACS-NSQIP database from 2008 to 2021 to identify male adult patients who underwent GS. Postoperative outcomes involved the occurrence of any, surgical and medical complications, as well as reoperation, readmission, and mortality within a 30-day postoperative time period. Univariable and multivariable assessment were performed to identify risk factors for complications while adjusting for possible confounders. RESULTS: The study included 4,996 GS patients with a mean age of 33.7 ± 15 years and BMI of 28.2 ± 5.1 kg/m2. White patients constituted 54% (n = 2713) of the cohort, and 27% (n = 1346) were obese. Except for 2020, there was a steady increase in GS cases over the study period. Outpatient surgeries were most common at 95% (n = 4730), while general surgeons performed the majority of GS (n = 3580; 72%). Postoperatively, 91% (n = 4538) of patients were discharged home; 4.4% (n = 222) experienced any complications. Multivariable analysis identified inpatient setting (p < 0.001), BMI (p = 0.023), prior sepsis (p = 0.018), and bleeding disorders (p = 0.047) as independent risk factors for complications. CONCLUSION: In this study, we analyzed 4996 male adult GS patients from the ACS-NSQIP database, revealing an increased caseload and significant general surgeon involvement. Risk factors like bleeding disorders, inpatient status, and prior sepsis were linked to postoperative complications, while BMI was crucial for predicting adverse events. Overall, our findings may aid in enhancing patient care through advanced preoperative screening and closer perioperative management. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Does Work Relative Value Unit Measure Surgical Complexity for Risk Adjustment of Surgical Outcomes?

INTRODUCTION: The purpose of this study was to determine whether the work relative value unit (workRVU) of a patient's operation can be useful as a measure of surgical complexity for the risk adjustment of surgical outcomes. METHODS: We retrospectively analyzed the American College of Surgeon's National Surgical Quality Improvement Program database (2005-2018). We examined the associations of workRVU of the patient's primary operation with preoperative patient characteristics and associations with postoperative complications. We performed forward selection multiple logistic regression analysis to determine the predictive importance of workRVU. We then generated prediction models using patient characteristics with and without workRVU and compared c-indexes to assess workRVU's additive predictive value. RESULTS: 7,507,991 operations were included. Patients who were underweight, functionally dependent, transferred from an acute care hospital, had higher American Society of Anesthesiologists class or who had medical comorbidities had operations with higher workRVU (all P < 0.0001). The subspecialties with the highest workRVU were neurosurgery (mean = 22.2), thoracic surgery (mean = 21.1), and vascular surgery (mean = 18.8) (P < 0.0001). For all postoperative complications, mean workRVU was higher for patients with the complication than those without (all P < 0.0001). For eight of 12 postoperative complications, workRVU entered the logistic regression models as a predictor variable in the 1st to 4th steps. Addition of workRVU as a preoperative predictive variable improved the c-index of the prediction models. CONCLUSIONS: WorkRVU was associated with sicker patients and patients experiencing postoperative complications and was an important predictor of postoperative complications. When added to a prediction model including patient characteristics, it only marginally improved prediction. This is possibly because workRVU is associated with patient characteristics.

The impact of race/ethnicity on pancreaticoduodenectomy outcomes for pancreatic cancer.

PURPOSE: To investigate the impact of race/ethnicity on surgical outcomes following pancreaticoduodenectomy for pancreatic cancer. METHODS: A retrospective review of patients undergoing pancreaticoduodenectomy for adenocarcinoma in the National Surgical Quality Improvement Program (NSQIP) database from 2014 to 2019. Patient and tumor characteristics and 30-day postoperative outcomes were compared. Multivariable logistic and linear regression models were conducted to investigate the relationship between race/ethnicity and surgical outcomes. RESULTS: Six thousand five hundred and sixty-two patients were included (84.5% White, 7.9% Black, 3% Hispanic, 4.6% Asian). Larger proportions of Blacks had preoperative American Society of Anesthesiologists class 3 or 4. There were no significant differences in tumor characteristics or operative techniques. A smaller proportion of Asians and Hispanics received neoadjuvant chemotherapy and/or radiation than Blacks and Whites. Relative to White, the Black race was independently associated with postoperative sepsis and reoperation. Both Black and Hispanic race/ethnicity were associated with prolonged intubation and delayed gastric emptying, and minorities races/ethnicities were associated with longer length of hospital stay. Relative to White, Hispanic, and Asian race/ethnicity were independently associated with a lower likelihood of neoadjuvant therapy (NAT) receipt. CONCLUSION: In ACS-NSQIP participating hospitals, non-White race/ethnicity was independently associated with adverse outcomes after pancreatic cancer resection. A possible disparity in NAT receipt may exist in Asian and Hispanic patients undergoing surgical resection.

Impact of surgeon specialty on clinical outcomes following esophagectomy for cancer.

BACKGROUND: The impact of surgeon and hospital operative volume on esophagectomy outcomes is well-described; however, studies examining the influence of surgeon specialty remain limited. Therefore, we evaluated the impact of surgeon specialty on short-term outcomes following esophagectomy for cancer. METHODS: The 2016-2019 American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) was queried to identify all patients undergoing esophagectomy for esophageal cancer. Surgeon specialty was categorized as general (GS) or thoracic (TS). Entropy balancing was used to generate sample weights that adjust for baseline differences between GS and TS patients. Weights were subsequently applied to multivariable linear and logistic regressions, which were used to evaluate the independent association of surgeon specialty with 30-day mortality, complications, and postoperative length of stay. RESULTS: Of 2657 esophagectomies included for analysis, 54.1% were performed by TS. Both groups had similar distributions of age, sex, and body mass index. TS patients more frequently underwent transthoracic esophagectomy, while GS patients more commonly received minimally invasive surgery. After adjustment, surgeon specialty was not associated with altered odds of 30-day mortality (adjusted odds ratio [AOR] 1.10 p = 0.73) or anastomotic leak (AOR 0.87, p = 0.33). However, TS patients exhibited a 40-min reduction in operative duration and faced greater odds of perioperative transfusion, relative to GS. CONCLUSION: Among ACS NSQIP participating centers, surgeon specialty influenced operative duration and blood product utilization, but not mortality and anastomotic leak. Our results support the relative safety of esophagectomy performed by select GS and TS.

Evaluation of the ACS NSQIP surgical risk calculator in patients undergoing common bile duct exploration.

PURPOSE: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator is a risk stratification tool to help predict risks of postoperative complications, which is important for informed decision-making. The purpose of this study was to evaluate the accuracy of the calculator in predicting postoperative complications in patients undergoing common bile duct (CBD) exploration. METHODS: A retrospective chart review was completed for 305 patients that underwent open and laparoscopic CBD exploration at a single institution from 2010 to 2018. Patient demographics and preoperative risk factors were entered into the calculator, and the predicted complication risks were compared with observed complication rates. Brier score, C-statistic, and Hosmer-Lemeshow regression analysis were used to assess discrimination and calibration. RESULTS: The observed rate exceeded the predicted rate for any complication (35.1% vs. 21%), return to operating room (5.9% vs. 3.6%), death (3.3% vs. 1%), and sepsis (3% vs. 2.4%). The model performed best in predicting serious complication (Brier 0.087, C-statistic 0.818, Hosmer-Lemeshow 0.695), surgical site infection (Brier 0.068, C-statistic 0.670, Hosmer-Lemeshow 0.292), discharge to rehabilitation facility (Brier 0.041, C-statistic 0.907, Hosmer-Lemeshow 0.638), and death (Brier 0.028, C-statistic 0.898, Hosmer-Lemeshow 0.004). In multivariable analysis, there was no statistically significant predicted complication type that affected the type of surgery. CONCLUSION: The calculator was accurate in predicting serious complication, surgical site infection, discharge to rehabilitation facility, and death. However, the model displayed poor predictive ability in all other complications that were analyzed.

Implication of American Society of Anesthesiologists Physical Status (ASA-PS) on tonsillectomy with or without adenoidectomy outcomes.

BACKGROUND: The American Society of Anesthesiologists Physical status classification (ASA-PS) is a simple categorization of a patient's physiological status during the perioperative period. The role of ASA-PS in predicting operative risk and complications following tonsillectomy with or without adenoidectomy (T ± A) has not been studied. The objective of the study was to identify the association of the pre-operative ASA-PS with 30-day complication rates and adverse events following T ± A. STUDY DESIGN: A retrospective analysis was performed using data from the American College of Surgeons' National Surgical Quality Improvement Program database (ACS NSQIP) of patients aged 16 years or older who underwent T ± A between 2005 and 2016. Patients were stratified into ASA-PS Classes I/II and III/IV. Patient demographics, preoperative comorbidities, pre-operative laboratory values, operation-specific variables, and postoperative outcomes in the 30-day period following surgery were compared between the two subsets of ASA-PS groups. RESULTS: On multivariate analysis, patients with ASA class III and IV were more likely to experience an unplanned readmission (OR 1.39, 95 % CI 1.09-1.76; p = 0.007), overall complications (OR 1.49, 95 % CI 1.28-1.72; p < 0.001), major complications (OR 1.52, 95 % CI 1.31-1.77, p ≤ 0.001), reoperation (OR 1.33, 95 % CI 1.04-1.69; p = 0.022), and extended length of stay >1 day (OR 1.78, 95 % CI 1.41-2.25; p < 0.001) following a T ± A. CONCLUSION: Higher ASA-PS classification is an independent predictor of complications following T ± A. Surgeons should aim to optimize the systemic medical conditions of ASA-PS classes III and IV patients prior to T ± A and implement post-operative management protocols specific to these patients to decrease morbidity, complications, and overall health care cost.

The effect of operative time on surgical-site infection following total shoulder arthroplasty.

BACKGROUND: Many factors contribute to the risk of surgical-site infection (SSI) following total shoulder arthroplasty (TSA). Operative time is a modifiable factor that may contribute to SSI occurrence after TSA. This study aimed to determine the correlation between operative time and SSI following TSA. MATERIALS AND METHODS: By use of the American College of Surgeons National Surgical Quality Improvement Program database, a total of 33,987 patient records were queried from 2006 to 2020 and sorted by operative time and the development of an SSI in the 30-day postoperative period. Odds ratios for the development of an SSI were calculated based on operative time. RESULTS: An SSI developed in the 30-day postoperative period in 169 of the 33,470 patients in this study, resulting in an overall SSI rate of 0.50%. A positive correlation was identified between operative time and the SSI rate. An inflection point was identified at an operative time of 180 minutes, with a significant increase in the rate of SSI occurrence for operative times >180 minutes. DISCUSSION AND CONCLUSION: Increased operative time was shown to be strongly correlated with an increased risk of SSI within 30 days following surgery, with a significant inflection point at 180 minutes. The target operative time for TSA should be <180 minutes to reduce the risk of SSI.

Predictors of mortality in nonagenarians undergoing abdominal aortic aneurysm repair: Analysis of the National Surgical Quality Improvement Program dataset.

BACKGROUND: The present study used the American College of Surgeons National Surgical Quality Improvement Program dataset to identify the predictors of 30-day mortality for nonagenarians undergoing endovascular aortic aneurysm repair (EVAR) or open surgical repair (OSR). METHODS: Patients aged >90 years who had undergone abdominal aortic aneurysm repair from 2005 to 2017 were identified using procedure codes. Those with operative times <15 minutes were excluded. The demographics, preoperative comorbidities, and postoperative complications of those who had died by 30 days were compared with those of the patients alive at 30 days. RESULTS: A total of 1356 nonagenarians met the criteria: 1229 (90.6%) had undergone EVAR and 127 (9.4%) had undergone OSR. The overall 30-day mortality was 10.4%. The patients who had died within 30 days were significantly more likely to have undergone OSR than EVAR (40.9% vs 7.2%; P < .001). They also had a greater incidence of dependent functional status (22.0% for those who had died vs 8.1% for those alive at 30 days; P < .001), American Society of Anesthesiology (ASA) classification of ≥4 (81.2% vs 18.8%; P < .001), perioperative blood transfusion (59.6% vs 20.3%; P < .001), postoperative pneumonia (12.1% vs 2.9%; P = .001), mechanical ventilation >48 hours (22.7% vs 2.6%; P < .001), and acute renal failure (12.1% vs 0.5%; P < .001). The EVAR group had a 30-day mortality rate of 2.6% in 1008 elective cases and 28.6% in 221 emergent cases. The OSR group had a 30-day mortality rate of 19.1% in 47 elective cases and 53.7% in 80 emergent cases. In the EVAR cohort, the 30-day mortality group had had a significantly greater incidence of dependent functional status (17% for those who had died vs 8% for those alive at 30 days; P = .004), ASA classification of ≥4 (76.4% vs 40.3%; P < .001), perioperative blood transfusion (57% vs 19%; P < .001), emergency surgery (71% vs 14%; P < .001), and longer operative times (150 vs 128 minutes; P = .001). CONCLUSIONS: Nonagenarians had an incrementally increased, but acceptable, risk of 30-day mortality with EVAR in elective and emergent cases compared with that reported for octogenarians and cohorts of patients not selected for age. We found greater mortality for patients with dependent status, a higher ASA classification, emergent repair, and OSR. These preoperative risk factors could help identify the best surgical candidates. Given these results, consideration for EVAR or OSR might be reasonable for highly selected patients, especially for elective patients with a larger abdominal aortic aneurysm diameter for whom the risk of rupture is higher.

Incidence of venous thromboembolism in benign urologic reconstructive cases.

PURPOSE: To evaluate the rate of perioperative venous thromboembolism (VTE) among patients undergoing common benign urologic reconstructive cases. We hypothesize that this rate will be lower than previously described. METHODS: We utilized the American College of Surgeons National Surgical Quality Improvement Project database from 2015 to 2019 to evaluate 30-day perioperative risk of VTE. Patients ≥ 18 years old undergoing benign urologic reconstructive cases were selected using Current Procedural Terminology (CPT) codes. Demographic, comorbidity, and operative variables were captured. The primary outcome was VTE within the 30-day postoperative period. RESULTS: We identified 8467 patients who met inclusion criteria. The majority of patients were male (> 95%) with an average age of 65 and BMI of 29.6. There were 23 VTE events (0.27%) within the 30-day perioperative period. Fourteen (14/59) procedures had a perioperative VTE. Many of the traditional factors for VTE including operative time and obesity significantly increased risk of VTE in univariate analysis. In multivariate analysis, only BMI (OR 1.09; 95% CI 1.01-1.12) and inpatient status (OR 4.42; 95% CI 1.9-10.2) were correlated with increased perioperative VTE. CONCLUSION: The rate of VTE among patients undergoing benign urologic reconstructive cases is low. Providers should continue to have high index of suspicion particularly for inpatients with high BMI in addition to other known risk factors for VTE.

Are Kids More Than Just Little Adults? A Comparison of Surgical Outcomes.

INTRODUCTION: While complication rates have been well described using the National Surgical Quality Improvement Program (NSQIP) and National Surgical Quality Improvement Program-Pediatric registries, there have been no direct comparisons of outcomes between adults and children. Our objective was to describe differences in postoperative outcomes between children and adults undergoing common surgical procedures. METHODS: Using data from 2013 to 2017, we identified patients undergoing laparoscopic appendectomy, laparoscopic cholecystectomy, thyroidectomy, and colectomy. Propensity score matching on gender, race, American Society of Anesthesiologists class, surgical indication, and procedure type was performed. Outcomes included surgical site infection (SSI), readmission rates, mortality/serious morbidity, and hospital length of stay and were analyzed using χ2 and student's t-test with statistical significance defined as P < 0.05. RESULTS: We matched 79,866 patients from 812 hospitals. Compared to adults, children had higher rates of SSI following appendectomy (4.12% versus 1.40%, P < 0.01) and cholecystectomy (0.96% versus 0.66%, P = 0.04), readmission following appendectomy (4.26% versus 2.47%, P < 0.01), and longer length of stay in all procedures. In adults, 30-day mortality/serious morbidity was higher for all procedures. CONCLUSIONS: Compared to adults, children demonstrate unique surgical complication and outcome profiles. Quality improvement efforts such as SSI prevention bundles and enhanced recovery protocols used in adults should be expanded to children.

Associations of gender, race, and ethnicity with disparities in short-term adverse outcomes after pancreatic resection for cancer.

BACKGROUND: Several studies have identified disparities in pancreatic cancer treatment associated with gender, race, and ethnicity. There are limited data examining disparities in short-term adverse outcomes after pancreatic resection for cancer. The aim of this study is to evaluate associations of gender, race, and ethnicity with morbidity and mortality after pancreatic resection for malignancy. METHODS: The American College of Surgeons National Surgical Quality Improvement database was retrospectively reviewed. The χ2 test and Student's t-test were used for univariable analysis and hierarchical logistic regression for multivariable analysis. RESULTS: Morbidity and major morbidity after pancreaticoduodenectomy are associated with male gender, Asian race, and Hispanic ethnicity, whereas 30-day mortality is associated with the male gender. Morbidity and major morbidity after distal pancreatectomy are associated with the male gender. Morbidity after pancreaticoduodenectomy is independently associated with male gender, Asian race, and Hispanic ethnicity; major morbidity is independently associated with male gender and Asian race, and mortality is independently associated with Hispanic ethnicity. CONCLUSIONS: Gender, race, and ethnicity are independently associated with morbidity after pancreaticoduodenectomy for cancer; gender and race are independently associated with major morbidity; and ethnicity is independently associated with mortality. Further studies are warranted to determine the basis of these associations.

Forecasting outcomes after cholecystectomy in octogenarian patients.

BACKGROUND: Although gallstone disease increases with aging, elderly patients are less likely to undergo cholecystectomy. This is because age itself is a negative predictor after cholecystectomy. The ACS-NSQIP risk calculator can therefore help surgeons decide whether to operate or not. However, little is known about the accuracy of this model outside the ACS National Surgical Quality Improvement Program. The aim of the present study is to evaluate the ability of the ACS-NSQIP model to predict the clinical outcomes of patients aged 80 years or older undergoing elective or emergency cholecystectomy. STUDY DESIGN: The study focused on 263 patients over 80 years of age operated on between 2010 and 2019: 174 were treated as emergencies because of acute cholecystitis (66.2%). Outcomes evaluated are those predicted by the ACS-NSQIP calculator within 30 days of surgery. The ACS-NSQIP model was tested for both discrimination and calibration. Differences among observed and expected outcomes were evaluated. RESULTS: When considering all patients, the discrimination of mortality was very high, as it was that of severe complications. Considering only the elective cholecystectomies, the discrimination capacity of ACS-NSQIP risk calculator has consistently worsened in each outcome while it remains high considering the emergency cholecystectomies. In the evaluation of the emergency cholecystectomy, the model showed a very high discriminatory ability and, more importantly, it showed an excellent calibration. Comparisons between main outcomes showed small or even negligible differences between observed and expected values. CONCLUSION: The results of the present study suggest that clinical decisions on cholecystectomy in a patient aged 80 years or older should be assisted through the ACS-NSQIP model.

The Geriatric Nutritional Risk Index Is an Independent Predictor of Adverse Outcomes for Total Joint Arthroplasty Patients.

BACKGROUND: Malnutrition affects patient outcomes after total joint arthroplasty (TJA). Although hypoalbuminemia has been used as a surrogate, there is no unanimous method for screening and assessing malnutrition. This study aimed to determine if malnutrition, as defined by the Geriatric Nutritional Risk Index (GNRI), is independently correlated with short-term (<30 days) postoperative complications and prognosis in patients undergoing TJA. METHODS: The 2016-2019 American College of Surgeons National Surgical Quality Improvement Program was queried for all patients aged >65 years who underwent TJA. Based on GNRI value, patients were divided into 3 groups: normal nutrition (GNRI >98), moderate malnutrition (GNRI 92-98), and severe malnutrition (GNRI <92). After adjusting for potential confounders, multivariable regression models were used to analyze the association between GNRI and patient outcomes. RESULTS: A total of 191,087 patients were included in the study. Prevalence of malnutrition based on body mass index (<18.5 kg/m2), albumin (<3.5 mg/dL), and GNRI (≤98) was 0.41% (784), 4.17% (7975), and 15.83% (30,258). Adjusted analysis showed that compared with normal nutrition, moderate and severe malnutrition status were associated with a higher rate of transfusion, readmission, and postoperative length of stay over 8 days (P < .05). Severe malnutrition was also associated with pneumonia, surgical site infection, urinary tract infection, sepsis, and revision surgery (P < .05). CONCLUSION: Malnutrition, as defined by GNRI, is an independent predictor of adverse outcomes after TJA, including 30-day readmission, revision surgery, and increased length of stay. GNRI can be used to routinely screen and assess patient nutritional status before TJA and counsel patients and families appropriately. LEVEL OF EVIDENCE: Level 3: Retrospective Cohort Study.

First 30 Days Wound-Related Complications in Young Smokers Following Primary Achilles Repair.

The Achilles tendon is frequently injured in the young to middle aged population. Previous studies have shown that there is an increased risk of delay in postsurgical wound healing amongst tobacco smoking patients with Achilles tendon injury. This study utilized the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. We included patients between the ages of 18 and 35 years who underwent primary Achilles tendon repair between years 2011 and 2020. The procedure type (with or without graft, CPT 27650 and 27652), patient demographics, and comorbidities were included. Primary outcomes of interest were 30-day readmission, minor complications, outcomes related to wound healing (wound disruption, superficial surgical site infection, deep incisional surgical site infection, organ-space site infections) and reoperations within 30 days of index surgery. A total of 1944 patients met the inclusion criteria for this study. One thousand six hundred and fifty-nine patients were nonsmokers, while 285 were smokers. Logistic regression showed no differences between smokers and nonsmokers (reference group) for 30-day readmission, reoperation, and minor complications. However, Black non-Hispanic patients were found to be 0.3 times (95% confidence interval: 0.1, 0.98) as likely to develop minor complications as compared to the White non-Hispanic patients. Wound-related complications after Achilles tendon repair remain low in younger (18-35 years) patients. When comparing clinical outcomes between nonsmokers and smokers, we found no statistically significant difference in this retrospective study.

What is the Accuracy of the ACS-NSQIP Surgical Risk Calculator in Emergency Abdominal Surgery? A Meta-Analysis.

BACKGROUND: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator provides an estimation of 30-d post-operative complications including mortality. This tool has the potential to both aid in decision-making for patients and their families and also in optimizing the clinical management of high-risk patients. However, it's utility in patients requiring emergency abdominal surgery has shown to be inconsistent outside of NSQIP participating institutions. This study undertook a meta-analysis to assess the calculator's accuracy in predicting mortality in these patients. METHODS: A literature search of PubMed, Medline and Cochrane databases was conducted between October 2019 to April 2020. The PubMed, Medline and Cochrane Databases were searched for relevant studies. The search strategy included studies from January 2013 to April 2020. Studies including elective surgery were excluded. A random effects model was used and fitted using restricted maximum likelihood estimation. The O:E ratio was used to validate the calculator's accuracy in predicting mortality. RESULTS: Six studies were included in the meta-analysis, with a total of 1835 patients undergoing emergency intra-abdominal surgery. The summary estimate of the O:E ratio of the ACS-NSQIP surgical risk calculator in predicting 30-d post-operative mortality was 1.06 (95% CI 0.74-1.51). There was significant heterogeneity between studies with a Cochrane Q of 11.96 (P = 0.04) and I2 = 57.5%. CONCLUSIONS: The ACS-NSQIP surgical risk calculator is a reliable predictor of mortality in this external cohort and has potential to be utilised in the multi-disciplinary care of patients undergoing emergency abdominal surgery.